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REGENCY HEALTH & HOME INSURANCE SERVICES
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REGENCY HEALTH & FINANCIAL INSURANCE GROUP
HOME INSURANCE QUOTE
73-261 Hwy 111 Suite 206, Palm desert, CA 92260
Ph:760-837-3761 fax:760-568-6791
www.regencyHealthOnline.net
DATE
NAME
MAILING ADDRESS
HOME PHONE       WORK PHONE           FAX  
OCCUPATION NAME 1      OCCUPATION NAME 2
DOB NAME 1                      DOB NAME 2
DWELLING:
PROPERTY ADDRESS
OCCUPANCY TYPE OF POLICY TO QUOTE
YEAR BUILT       # OF STORIES           SQUARE FOOTAGE  
GARAGE ATTACHED Y/N       # OF CARS           POOL/SPA?  
CENTRAL FIRE/BURGLER ALARM             ALARM COMPANY
(CIRCLE ANSWER)       GATED COMMUNITY                                                                                          GUAREDED  
DISTANCE TO BRUSH?                   PREV CLAIMS?
PRIOR INS.CAREER       POLICY           EXP DATE  
OWN ANY DOGS? IF YES WHAT KIND OF BREED?
COVERAGES:
PURCHASE PRICE    RELACEMENT COST
PERSONAL PROPERTY       LIABLITY           DEDUCTIBLE  
EARTHQUAKE SHEDULE ANY ARTICLE
ANTICIPATED EFFECTIVE DATE
REFERRED BY
SPECIAL INSTRUCTION
EMAIL ADDRESS
La Jolla Insurance Services